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Prospective study of endoscopic variceal ligation (EVL) plus endoscopic sclerotherapy vs. EVL alone for the treatment of esophageal varices
198
Poster Sessions
~-9-~ TERLIPRESSIN USE IN PATIENTS WITH DECOMPENSATED LIVER DISEASE AND MULTIPLE ORGAN FAILURE: EFFECTS AND SIDE EFFECTS Georg Auzinger, Rachael Harry, Julia Wendon. Institute of Liver Studies,
LITU, King's College Hospital London, UK The circulatory disturbances seen in severe sepsis and end stage liver failure are similar. In established septic shock plasma vasopressin levels are inappropriately low and vasopressin administration can reverse catecholamine resistance. Terlipressin a vasopressin analogue is frequently used in patients with end stage liver disease complicated by hepatorenal syndrome or variceal hemorrhage. Methods: Retrospective study of effects and side effects of terlipressin therapy in 11 patients with decompensated liver disease and multiple organ failure. Splanchnic perfusion was monitored in all patients via gastric tonometry. SOFA scores, hemodynamic and metabolic parameters as well as liver function tests were measured sequentially over a 72 hour period and their change over time was compared to baseline levels with ANOVA for repeated measurements. Results: Eight of 11 patients were in septic shock and 7 patients required renal replacement therapy. All patients were ventilated. The mean SOFA score was 17 and did not change throughout the observation period. Terlipressin significantly reduced vasopressor requirements during the study period (p < 0.05), mean arterial pressure increased at 4 hours (p < 0.05), stroke volume and CI remained constant. There was a significant increase in the gastric mucosal - arterial CO2 gap over time (0.66 kPa-3.5 kPa, p = 0.005) indicating splanchnic hypoperfusion. Conclusion: Terlipressin can improve systemic hemodynamics but might induce splanchnic ischemia in patients with decompensated liver disease and multiple organ failure.
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Ivanka Stamenkovic 1, Goran Bjelakovic I , Gordana Kocic 2, Dusica Pavlovic 2.1 Clinic of Gastroenterology and Hepatology, Clinical
Center Nis, Serbia; 2Institute of Biochemistry, Medical Faculty, University of Nis, Serbia, Yugoslavia It is well known that liver cirrhosis is accompanied with impaired renal excretion of sodium and water. Sodium retention in the clinical course of liver cirrhosis is one of pathogenetic factors for the formation of ascites. The aim of the study was to compare urinary sodium excretion in liver cirrhosis with and without ascites. The completion of the 24-hour urine specimen was assesed by measuring the levels of urinary creatinine. Thirty nine patients with liver cirrhosis confirmed by clinical, biochemical, laparascopic, and histologic examinations, were divided into two groups a) without ascites (9) and b) with ascites (31). We measured the 24-h urinary sodium and urinary creatinine concentration in both group of patients. Urinary sodium concentrations were determined by flame photometry and urinary creatinin concentration was measured by by the Jaffe reaction. In the group of patients with liver cirrhosis and ascites mean 24-h urinary sodium concentration was 42.84 mmol or 55.04 mmol/L and in the group without ascites was 104.7 mmol or 92.56 mmol/L and was statistically significant higher than in the group with ascites (p < 0.05). Urinary creatinine concentration in group with ascites was 13.13 mg kg b.w./24 h in males and 11.98 mg kg b.w./24 h in females and in group without ascites 17.12 mg kg b.w./24 h in males and 10.8 mg kg b.w./24 h in females. We conclude that in patients with liver cirrhosis renal sodium retention is the main factor in pathogenesis of ascites formation.
~2] ~O0-I NEW PROPOSAL FOR THE SERUMASCITES ALBUMIN GRADIENT CUT OFF VALUE Goran Bjelakovic 1, Tomislav Tasic l, Aleksandar Nagorui 1, Ivanka Stamenkovic I , Gordana Bjelakovic 2. 1Clinic of Gastroenterology
and Hepatology, Clinical Center Nis, Serbia; 2Institute of Biochemistry, Medical Faculty, University of Nis, Serbia, Yugoslavia Serum ascites albumin gradient (SAAG) has long been recognized as a reliable biochemical marker that can help in differential diagnosis of ascites. Values under 11 g/L indicate that patient with ascites has portal hypertension and vise versa. Because of poor sensitivity (Se) and specificity (Sp) of SAAG in some of previous studies and possibilities owing to new statistical methods like Receiver Operating Characteristic (ROC) analysis it is interested to define new cut off value with maximal Se and Sp. Investigation included 171 patients, 130 with cirrhotic, mean age 60 years, and 41 with malignant ascites, mean age 63 years. In the group with malignant ascites 6 pts. (14.63%) had liver metastasis, but only two of them (4.88%), massive liver metastasis that caused portal hypertension. The mean value of SAAG (4-SD) in the group of patients with cirrhotic ascites was 21.89 4- 8.34 g/L and was statistically significant higher than SAAG in group with malignant ascites of 11.17 4- 7.13 g/L, (p < 0.001). Cut off value for SAAG of 11 g/L had high sensitivity (97.56%) but low specificity (46.34%), so we decide to determine new cut off value using ROC analysis. With probability p < 0.05, interval of reliability was 11.2-19.7 g/L with cut off value of 15.86 g/L. We conclude that cut off value for the SAAG has to be corrected to higher level to achieve maximal sensitivity and specificity, helping in differential diagnosis of ascites.
URINARY SODIUM EXCRETION IN LIVER CIRRHOSIS - ROLE IN ASCITES FORMATION
PROSPECTIVE STUDY OF ENDOSCOPIC VARICEAL LIGATION (EVL) PLUS ENDOSCOPIC SCLEROTHERAPY VS. EVL ALONE FOR THE TREATMENT OF ESOPHAGEAL VARICES
Juan Bobadilla-Diaz, Graciela Castro-Narro, Ma. Eugenia ICaza-Chavez, Jorge Ibarra-Palomino, Eduardo Sanchez-Cortes, Sarai Gonzalez-Huezo, Javier Elizondo-Rivera. Department of Gastrointestinal Endoscopy,
INCMNSZ, Mexico City, Mexico Background: Studies of efficacy of EVL plus sclerotherapy (ES) vs. EVL alone for the treatment of esophageal varices (EV) have shown conflicting results. Aim: Compare efficacy of EVL plus ES vs. EVL alone for the treatment of EV. Methods: Patients with variceal hemorrhage were randomly assigned to receive EVL followed by ES (group 1) or EVL alone (group 2) and followed for 3 years. EVL was performed at 2-week intervals until EV eradication. Afterwards, endoscopic follow-up was performed at 1, 3, 6, 12, 24 and 36 months. Procedure related complications were recorded, as were recurrence of EV and variceal bleeding during follow-up. Results: 33 patients were included (18 in group 1 and 15 in group 2, 18 male). Clinical and demographic data were similar in both groups. EV were eradicated in 4.8 sessions in group 1 and 3.4 sessions in group 2. One patient in group 2 had variceal bleeding, recurrence of EV was documented in 2 patients in group 1 and 3 patients in group 2. Portal hypertensive gastropathy developed in 1 patient in group 1 and 4 patients in group 2. Conclusions: No clinical advantage was demonstrated with EVL plus ES vs. EVL alone in the treatment of EV. EVL patients required fewer sessions to eradicate EV, but developed portal hypertensive gastropathy more frequently.
Poster Sessions
~-9-~ TERLIPRESSIN USE IN PATIENTS WITH DECOMPENSATED LIVER DISEASE AND MULTIPLE ORGAN FAILURE: EFFECTS AND SIDE EFFECTS Georg Auzinger, Rachael Harry, Julia Wendon. Institute of Liver Studies,
LITU, King's College Hospital London, UK The circulatory disturbances seen in severe sepsis and end stage liver failure are similar. In established septic shock plasma vasopressin levels are inappropriately low and vasopressin administration can reverse catecholamine resistance. Terlipressin a vasopressin analogue is frequently used in patients with end stage liver disease complicated by hepatorenal syndrome or variceal hemorrhage. Methods: Retrospective study of effects and side effects of terlipressin therapy in 11 patients with decompensated liver disease and multiple organ failure. Splanchnic perfusion was monitored in all patients via gastric tonometry. SOFA scores, hemodynamic and metabolic parameters as well as liver function tests were measured sequentially over a 72 hour period and their change over time was compared to baseline levels with ANOVA for repeated measurements. Results: Eight of 11 patients were in septic shock and 7 patients required renal replacement therapy. All patients were ventilated. The mean SOFA score was 17 and did not change throughout the observation period. Terlipressin significantly reduced vasopressor requirements during the study period (p < 0.05), mean arterial pressure increased at 4 hours (p < 0.05), stroke volume and CI remained constant. There was a significant increase in the gastric mucosal - arterial CO2 gap over time (0.66 kPa-3.5 kPa, p = 0.005) indicating splanchnic hypoperfusion. Conclusion: Terlipressin can improve systemic hemodynamics but might induce splanchnic ischemia in patients with decompensated liver disease and multiple organ failure.
[-~
Ivanka Stamenkovic 1, Goran Bjelakovic I , Gordana Kocic 2, Dusica Pavlovic 2.1 Clinic of Gastroenterology and Hepatology, Clinical
Center Nis, Serbia; 2Institute of Biochemistry, Medical Faculty, University of Nis, Serbia, Yugoslavia It is well known that liver cirrhosis is accompanied with impaired renal excretion of sodium and water. Sodium retention in the clinical course of liver cirrhosis is one of pathogenetic factors for the formation of ascites. The aim of the study was to compare urinary sodium excretion in liver cirrhosis with and without ascites. The completion of the 24-hour urine specimen was assesed by measuring the levels of urinary creatinine. Thirty nine patients with liver cirrhosis confirmed by clinical, biochemical, laparascopic, and histologic examinations, were divided into two groups a) without ascites (9) and b) with ascites (31). We measured the 24-h urinary sodium and urinary creatinine concentration in both group of patients. Urinary sodium concentrations were determined by flame photometry and urinary creatinin concentration was measured by by the Jaffe reaction. In the group of patients with liver cirrhosis and ascites mean 24-h urinary sodium concentration was 42.84 mmol or 55.04 mmol/L and in the group without ascites was 104.7 mmol or 92.56 mmol/L and was statistically significant higher than in the group with ascites (p < 0.05). Urinary creatinine concentration in group with ascites was 13.13 mg kg b.w./24 h in males and 11.98 mg kg b.w./24 h in females and in group without ascites 17.12 mg kg b.w./24 h in males and 10.8 mg kg b.w./24 h in females. We conclude that in patients with liver cirrhosis renal sodium retention is the main factor in pathogenesis of ascites formation.
~2] ~O0-I NEW PROPOSAL FOR THE SERUMASCITES ALBUMIN GRADIENT CUT OFF VALUE Goran Bjelakovic 1, Tomislav Tasic l, Aleksandar Nagorui 1, Ivanka Stamenkovic I , Gordana Bjelakovic 2. 1Clinic of Gastroenterology
and Hepatology, Clinical Center Nis, Serbia; 2Institute of Biochemistry, Medical Faculty, University of Nis, Serbia, Yugoslavia Serum ascites albumin gradient (SAAG) has long been recognized as a reliable biochemical marker that can help in differential diagnosis of ascites. Values under 11 g/L indicate that patient with ascites has portal hypertension and vise versa. Because of poor sensitivity (Se) and specificity (Sp) of SAAG in some of previous studies and possibilities owing to new statistical methods like Receiver Operating Characteristic (ROC) analysis it is interested to define new cut off value with maximal Se and Sp. Investigation included 171 patients, 130 with cirrhotic, mean age 60 years, and 41 with malignant ascites, mean age 63 years. In the group with malignant ascites 6 pts. (14.63%) had liver metastasis, but only two of them (4.88%), massive liver metastasis that caused portal hypertension. The mean value of SAAG (4-SD) in the group of patients with cirrhotic ascites was 21.89 4- 8.34 g/L and was statistically significant higher than SAAG in group with malignant ascites of 11.17 4- 7.13 g/L, (p < 0.001). Cut off value for SAAG of 11 g/L had high sensitivity (97.56%) but low specificity (46.34%), so we decide to determine new cut off value using ROC analysis. With probability p < 0.05, interval of reliability was 11.2-19.7 g/L with cut off value of 15.86 g/L. We conclude that cut off value for the SAAG has to be corrected to higher level to achieve maximal sensitivity and specificity, helping in differential diagnosis of ascites.
URINARY SODIUM EXCRETION IN LIVER CIRRHOSIS - ROLE IN ASCITES FORMATION
PROSPECTIVE STUDY OF ENDOSCOPIC VARICEAL LIGATION (EVL) PLUS ENDOSCOPIC SCLEROTHERAPY VS. EVL ALONE FOR THE TREATMENT OF ESOPHAGEAL VARICES
Juan Bobadilla-Diaz, Graciela Castro-Narro, Ma. Eugenia ICaza-Chavez, Jorge Ibarra-Palomino, Eduardo Sanchez-Cortes, Sarai Gonzalez-Huezo, Javier Elizondo-Rivera. Department of Gastrointestinal Endoscopy,
INCMNSZ, Mexico City, Mexico Background: Studies of efficacy of EVL plus sclerotherapy (ES) vs. EVL alone for the treatment of esophageal varices (EV) have shown conflicting results. Aim: Compare efficacy of EVL plus ES vs. EVL alone for the treatment of EV. Methods: Patients with variceal hemorrhage were randomly assigned to receive EVL followed by ES (group 1) or EVL alone (group 2) and followed for 3 years. EVL was performed at 2-week intervals until EV eradication. Afterwards, endoscopic follow-up was performed at 1, 3, 6, 12, 24 and 36 months. Procedure related complications were recorded, as were recurrence of EV and variceal bleeding during follow-up. Results: 33 patients were included (18 in group 1 and 15 in group 2, 18 male). Clinical and demographic data were similar in both groups. EV were eradicated in 4.8 sessions in group 1 and 3.4 sessions in group 2. One patient in group 2 had variceal bleeding, recurrence of EV was documented in 2 patients in group 1 and 3 patients in group 2. Portal hypertensive gastropathy developed in 1 patient in group 1 and 4 patients in group 2. Conclusions: No clinical advantage was demonstrated with EVL plus ES vs. EVL alone in the treatment of EV. EVL patients required fewer sessions to eradicate EV, but developed portal hypertensive gastropathy more frequently.